Thursday, July 17, 2008

The Last Post at least on Blogger. Dr Shock is now writing on his own domain name. So please update your bookmarks, RSS Feeds and e-mail subscriptions on ShockMD.com or for Dutch readers easier to remember: DokterShock.nl.

Wednesday, July 16, 2008

Why do we crave love so much, even to the point that we would die for it? To learn more about our very real, very physical need for romantic love, Helen Fisher and her research team took MRIs of people in love -- and people who had just been dumped.

EXTRA, EXTRA, READ ALL ABOUT IT! That’s right folks, this week I shall be dishing as much dirt on the latest rumours, gossip and scandal that the blogosphere can handle, and all from a rather slanderous angle!

Tuesday, July 15, 2008

Chronic hypokalemia due to excessive cola consumption, a case report in Cases Journal

A 52-year-old man was noted to have severe chronic hypokalemia despite discontinuation of diuretic treatment for hypertension and aggressive oral potassium supplementation. His serum potassium normalized temporarily when he was hospitalized, but hypokalemia recurred after discharge. He complained of generalized weakness and fatigue, and occasional loose stools. Physical examination showed mild generalized muscle weakness. Laboratory testing ruled out renal potassium wasting. A dietary history revealed that he was consuming 4 liters of cola per day, with a calculated fructose load of 396 grams per day. Since fructose absorption in the small bowel is relatively inefficient, this probably led to an osmotic diarrhea and GI potassium wasting. Physicians should ask their patients about soft drink consumption when they encounter unexplained hypokalemia.

A recent systematic review and meta-analysis shows that at worse antidepressants are not effective for juvenile depression and at best better research might proof this conclusion wrong.Juvenile meaning depression among children and adolescents.

The figure above is the forest plot of this systematic review:Forest plot of rate ratios (RR, with 95% CI) of responses to drug or placebo in 30 randomised double-blind placebo-controlled comparisons of rates of ‘response’ to antidepressants v. placebo, with overall pooled RR (1.22; 95% CI 1.15–1.31; blue diamond).

Antidepressants of all types showed limited efficacy in juvenile depression, but fluoxetine might be more effective, especially in adolescents. Studies in children and in severely depressed, hospitalised or suicidal juvenile patients are needed, and effective, safe and readily accessible treatments for juvenile depression are urgently required.

there were 30 contrasts arising from 29 randomised controlled trials for meta-analysis

All studies included provided drug doses consistent with contemporary paediatric practice, based on body-weight-adjusted daily dosing (mg/kg) considered standard for treating adult major depressive disorder

average exposure time of 8.7 weeks (median=8, range 1–12)

primary outcomes for meta-analysis a priori as responder status, based on changes in clinical ratings from intake to last observation point (as defined in each trial) involving substantial improvement, typically a 50% or greater reduction in symptomatic ratings of depression on standardised scales. This is a weak outcome measure, remission should be the aim of treatment mostly defined as a score of 7 or lower on the Hamilton Depression Rating Scale

pooled overall effect size, based on meta-analysis to determine a pooled rate ratio and its confidence interval for all 30 trials, yielded a value of 1.22 (95% CI 1.15–1.31)

There was no difference in efficacy between different antidepressant classes such as SSRI's or TCAs. Moreover analysis fail to support the possibility that SRIs may be superior in efficacy to tricyclic antidepressants

The three age groups yielded an interesting progression in rate differences and corresponding decreases of NNT by age (about 21 for children, 10 juveniles of mixed ages and 8 for adolescents)

Explanations for the disappointing results:

Relatively high rates of response to placebo or other non-specific interventions

My opinion is that selection of juveniles with relatively heterogeneous illnesses can explain the lack of efficacy. Maybe only juveniles with melancholic or psychotic depression respond to antidepressants. This is comparable to depression in adults.

sampling of young patients with depression may include a high proportion of relatively mildly ill patients, who have most probably never received in-patient treatment, and who are more likely to improve spontaneously with or without additional effects of placebo treatment

Moreover, it remains to be seen whether the brain of juveniles is as susceptible to antidepressants as with adults. Depression in a developing brain may be different from depression in an adult brain and the influence of antidepressants on a developing brain might be lacking. This is supported by the finding in this meta-analysis that older juveniles respond better than younger ones. Here is a video about teens and their developing brain, thanks PsychCentral

Importantly, prepubertal children with depression may differ biologically from adolescents or adults, and it remains unclear whether depression in prepubertal children is a substantially different disorder from that found in adolescents or adults, perhaps including developmental differences in either the pharmacodynamics of antidepressants or in their clinical effects.

Digestion breaks down lipids into hydroperoxides. (Cooked meats are worse.) The stomach acts as a "bioreactor"-- the longer time the food/fat spends there, the greater the lipid peroxidation. An experiment with rats found that eating a meal soaked in red wine completely blocked the the generation of malondialdehyde, a common lipid peroxidation cytotoxin.Humans who ate the meal and drank a 200ml (1/4 bottle) of wine had a 75% reduction in MDA as compared to no wine.

Monday, July 14, 2008

rTMS is using electromagnetic fields to influence the brain,on this video you can see magnetic fields although not related to rTMS. The comment is very technical but the video is amazing, even scary.From: Environmental graffiti

Combining their scientific experience with artistic instinct in sound, animation and programming they have created a ‘magnetic magnum opus’ - a ‘tour de force’ of immense invisible force brought down to human scale. And it is precisely the meeting of scale that makes the work so fascinating - to think that these tiny pulsating currents surround our planet on a scale inconceivable to man is not only a humbling thought, but an uplifting one. The inherent beauty of nature is again, in Wordswoth’s words, too much with us.

Sunday, July 13, 2008

Netter's Anatomy Flash Cards: Need some help with your anatomy and physiology class? Check out this slick native app that lets you test yourself on how the knee bone connects to the thigh bone. There's a neuroscience version, too. (iPhone 2.0, $39.99)

ePocrates: This app for drug dosing, interaction and pricing is a boon for doctors. (iPhone 2.0, Free)

iPhone is everywhere on the net and blogosphere,couldn't resist posting about the new iphone. Yes, Dr Shock has one, already for 6 months although the iphone came available only 2 days ago in The Netherlands. Where is The Netherlands anyway, who cares.

BrainInfo is designed to help you identify structures in the brain. If you provide the name of a structure, BrainInfo will show it and tell you about it. If you don't know the name but can locate the structure in the Template Atlas of the Primate Brain, BrainInfo will tell you its name and other facts about it.

This is what BrainInfo can do for you:If you type in the name of a brainstructure you can see were it is, you can read recent literature about the structure on PubMed, which species have it and of course you can see it in anatomical pictures. From some structures you can learn about the internal structures, the cells it contains, which genes are expressed there, or the connectivity to other structures.

Friday, July 11, 2008

Hybrid's illustrations and animations extend beyond the boundary of highly informative graphics: they enter the realm of high art, achieving a combination of Truth and Beauty.If you're looking for people who will go the extra yard, deliver on time and make you look good, Hybrid Medical Animation is your first stop

Idiomorf is a Graphic Design Company that specializes in designing graphic diagrams, detailed charts, tables, maps and technical illustrations, which are used to illustrate an idea. These illustrations and animations are used to relay information quickly and without words, minimizing the need for costly writing and translation.

The chocolate condition was a cocoa drink with 321 mg of flavanols thrice daily for 30 days, not your average candy bar. The control condition only contained 25 mg flavanols. In this research CocoaPro cocoa powder made by Mars was used.

How does it work?

We observed the absorption of flavanols in diabetic patients, accompanied by increases in plasma flavanol metabolites, leading to a dose-dependent improvement of endothelial function, corroborating our findings from previous studies in nondiabetic populations

Impaired endothelial function is a key factor for the development of atherosclerosis and its complications in diabetic patients. That's why this is important.

This could be an alternative approach to the prevention of atherosclerosis in this population which is highly needed.

This was a study well done. First the researchers conducted a feasibility study on 10 patients to determine the appropriate dosing, assess safety and tolerability, and measure the effect size of the intervention in order to calculate the appropriate sample size of the subsequent efficacy study.

The efficacy study was undertaken using a randomized, doublemasked, parallel-group design and included 44 patients randomlyallocated to a treatment group (321 mg of flavanols per dose; 3 doses per day) or a control group (25 mg of flavanols per dose; 3 doses per day). Each group ingested a single dose of either treatment or control 3 times a day over a period of 30 days. The authors assessed the acute effects, 2 h after ingestion of the control or the cocoa drink, and the long-term effects, on days 8 and 30.

The accompanying editorial concludes:

These findings expand previous observations to patients with type 2 diabetes and represent a further step in our understanding of the vascular effects of flavanol-rich cocoa.However, although endothelial function has been shown to predict future cardiovascular events (20), randomized, large scale clinical trials assessing relevant clinical outcomes are necessary before any recommendations are made regarding dietary supplementation with flavanol-rich cocoa.

Wednesday, July 9, 2008

Most things in life can be related, one way or another, to an episode of Seinfeld.

It's true. That TV show which claimed to be "about nothing" pretty much said everything that needed to be said about, well, everything.

Take this week's Grand Rounds, the best of the Medical Blogosphere. It's totally Seinfeld. Every post. Why I can hear Jerry, even now...

This weeks grand round is related to episodes of Seinfeld, never heard about this sitcom but the connection to the posts is well done. Love the video's related to the posts, great job, go and read at The Blog that Ate Manhattan

When both SSRIs and NSAIDs are concomitantly used, it would be sufficient to treat 250 patients per year for 1 case of upper gastrointestinal (GI) tract bleeding to be attributed to such combination, and 500 patients per year if SRIs are concomitantly used with antiplatelet drugs.

The authors of this study were the first to point out the dangers of combining SSRIs with NSAIDs in 1999.

In the present study they found an increased risk although smaller than in their previous publication. Increasing use of acid-suppressing medication and declining cohort prevalence of Helicobacter pylori infection and its widespread treatment might account for this smaller risk. They used the same method with another United-Kingdom based general practitioner database in a more recent study period.

Dosage and duration of using these medications was not associated with GI tract bleeding

Use of acid-suppressing agents limits such increased risk.

With SRIs alone it would be necessary to treat approximately 2000 patients per year with SRIs for 1 case of upper GI tract bleeding to be attributed to them, which indicates that the risk is rather low in the general population.

But when they are combined with NSAIDs or antiplatelet drugs, the number of patients needed to be treated per year for 1 case of upper GI tract bleeding decreases remarkably. These data indicate that in such a high-risk population, the use of acid-suppressing agents would save a relevant number of cases and is worthwhile.

So when you have to use both drugs be careful out there. This is not about the occasional NSAID for a headache while taking antidepressants but using both medications at least for weeks could have these side-effects. Even than some people will not get these kind of complications while others will get them after 2 weeks of medication use. Vulnerability is the explaining factor in these matters.

Vulnerability to gastrointestinal side-effects is that recognizable to some of you? Please let me know in the comments.

Tuesday, July 8, 2008

On Medpage today a summary of a variety of alternative approaches that apply electrical currents to the brain are in the research pipeline, and one is FDA approved. A summary of VNS, rTMS, magnetic seizure therapy, deep brain stimulation , TDCS and Implantable cortical stimulation. Never heard of that last one, a new form of neurostimulation?

Implantable cortical stimulation

Another early-stage investigational technology takes vagus nerve stimulation a step farther. Instead of delivering electrical pulses to a nerve, it sends them to the surface of the brain. Seattle-based Northstar Neurosciences is testing a system that, like vagus nerve stimulation, inserts a pulse generator in the patient's chest. An electrical lead is passed into the skull through a surgically drilled hole, terminating on the dural membrane over the cortex.

A nice overview.

On Psych Central: Brain Pacemaker Shows PotentialA short description of the history of deep brain stimulation and two case reports with exceptional indications for deep brain stimulation: one patient was treated for body dysmorphic disorder and the other was treated for debilitating headaches.

Body dysmorphic disorder is excessive preoccupation with minor or imagined flaws in appearance. Dr. Anderson’s patient was a 20-year-old man who obsessed on perceived flaws with his nose and other facial features. He had attempted suicide once, and described his life as a “living hell.” Eight months after DBS surgery, the patient reported mild depression and obsessive compulsive disorder, but no symptoms of body dysmorphic disorder.

The second patient was a 43-year-old woman who suffered paroxysmal hemicrania headaches around the orbit of her right eye. She would typically get 10 to 20 attacks per day, each lasting 2 to 20 minutes. The headaches did not respond to either medications or a nerve block. But as soon as the DBS device was turned on, the woman reported the pain went away.

Pharmacological augmentation of antidepressant therapy has shown promise in the treatment of residual fatigue. Modafinil and bupropion are the only two augmentation strategies published on this subject

Now lets' be careful, these observations about depression and fatigue were published in a review, not a systematic review. You could at best consider these observations as the opinion of an expert, not the scientific truth about the relationship between fatigue and depression. Moreover most of these observation are recognizable but don't have to be true. I have linked as much as possible to the references used by the author.

To my opinion does fatigue play an important role in depression but you can't say that fatigues always implies depression. Even in science this mistake is often made. It is comparable to using depression severity scales in somatic ill patients and concluding that a large part of these patients have a depression because they have a high score on these scales. They have a high score due to their medical illness not due to a depression, you need a diagnostic scale for that.

Sunday, July 6, 2008

Born in 1942 into a Jewish family in Brooklyn, the teenage Lou Reed was subjected to electroconvulsive therapy to "cure" his homosexuality. He worked as a house songwriter for Pickwick Records before finding cult fame with art-rock band The Velvet Underground. Post-VU, he released a succession of acclaimed albums, most significantly 1972's 'Transformer', whose themes of drug use and cross-dressing chimed with the mood of the glam-rock movement spearheaded by his friend David Bowie.

Since recent I am participating in the update of the guidelines for ECT in The Netherlands. That gave me the privilige to meet patients treated or being treated with ECT, mostly continuation ECT. In a meeting with them a couple of weeks ago they made remarks about the treatment and how the new guideline could improve ECT. Their experience, critique will be used for the new guidelines. Discussing ECT with these hands on experienced patients was a pleasure and very informative.

A week after that I had a meeting with (ex)patients of Mental Health Care and their significant others. Some of them had experience with ECT in the past. Comparable to Lou Reed some of them had been treated in the sixties with ECT for comparable absurd indications. We had a very lively and instructive discussion about ECT in the past and how ECT is used nowadays. To me these meetings are of immense importance, it changes your perspective on what your doing and how your doing it.

Saturday, July 5, 2008

In a recent study, radiologists gave nearly 1,500 women at an increased risk of breast cancer both a mammogram and a stereo mammogram. As a result, the stereo mammograms increased detection of cancer by 23 percent and decreased false alarms by 46 percent.

The stereo mammogram

U.S. scientists are experimenting with new ways to view breast X-rays in 3-D, so that today's mammograms can provide a clearer picture of any existing tumors. Some of those methods include wearing special 3-D glasses as well as using a new camera.

Transcranial direct current stimulation (TDCS) could improve memory in participants asked to learn and then recall a list of 12 words. The effect was significant in the early learning stages: in the first few trials, in which participants were given the same list over and over again, people in the treatment group could remember more words. But the learning curve for those working without the device quickly caught up to the zapped learners.

At first the encoding of of the words is better in subjects treated with TDCS. Improving the encoding by training this test catches up after a while. The treatment with TDCS was done prior to the learning task, what if it was done during the test?

What is TDCS?

The device is simple: a nine-volt battery that's been approved by the Food and Drug Administration for delivering drugs across the skin is connected to large flat sponges that are moistened and then applied to the head. It delivers a gentle 2 to 2.5 milliamps of current spread over a 20 to 50 square millimeter area of the scalp for up to 15 minutes. Little of that current actually reaches the brain--about half is shunted away from the target area, and the other half quickly dissipates as it gets farther from the scalp. The target in this research was the part of the brain known as the dorsolateral prefrontal cortex, a brain area involved in higher-level organization and planning, as well as in working memory. Because activity in this region has been shown in previous imaging studies to predict an individual's ability to recall information, the idea is that giving it an electrical boost will enhance memory function.

TDCS is something completely different than ECT. It is not used to elicit a general seizure, it doesn't require anesthesia and it is not tested properly for the treatment of depression.

Side-effects of TDCSIn the afore mentioned article only a slight dizziness was reported as side effect. In a upcoming publication in Brain Stimulation other side-effects are reported with TDCS. In 4 out of 4 patients treated with a higher dose (2mAmpere) during each active TDCS session with over 20 minutes (15-second ramp in and ramp out each) of stimulation on 5 days per week during a 2-week period, skin lesions were present. Generally, these lesions occurred after the fourth or fifth DC-stimulation, showed stable superficial extensions during further tDCS, and healed without scars about 1-3 weeks after the end of tDCS treatment.

The occurrence of lesions may depend on the intensity and duration of TDCS as well as on the impedance between electrode and skin.

Friday, July 4, 2008

After remission on ECT for psychotic depression the combination of nortriptyline and ECT prevented relapse or recurrence in 11 of 16 patients during follow-up of 2 years, of the 17 nortriptyline treated patients only 5 were considered without relapse or recurrence. The mean survival time until relapse was 23 months in the ECT with nortriptyline group and 16 months in the nortriptyline group.

ECT or electroshock is the only treatment in psychiatry that is stopped when successful. Usually treatment is continued with an antidepressant or the combination of an antidepressant with lithium. Tricyclic antidepressants are mostly used because most research on continuation treatment after ECT is done with these antidepressants.

Most research is done with adults not specifically with elderly. When a severely depressed elderly is admitted to our ward and recovers I usually advice them not to stop their antidepressants. I have seen to many relapse when tapering or stopping their antidepressants. There time left is to valuable to spent on psychiatric wards.

A severe form of depression, psychotic depression usually warrants ECT treatment in the elderly. This severe form of depression leads to deterioration fast which can be interrupted effectively by ECT.

In this research a group of elderly with psychotic depression was treated with ECT and nortrityline. When remitted (33/38, 86.8%) they were randomized single blind to continuation ECT with nortriptyline or nortriptyline alone. The high percentage of remitters is no exception with ECT for psychotic depression.

The combination of continuation ECT with nortriptyline is exceptional. In adults a recent trial comparing continuation ECT to nortriptyline with lithium showed no significant difference in relapse during a 6 month follow-up. You can read about this study published in the Archives of General Psychiatry in a post on this blog. Nevertheless both treatments were well tolerated although cognitive side effects were not adequately monitored.

Other limitations of this study are the small sample size, only 14 had initially received pharmacotherapy for their episode before ECT.

Tuesday, July 1, 2008

Drug use does not appear to be related to drug policy, as countries with more stringent policies (e.g., the US) did not have lower levels of illegal drug use than countries with more liberal policies (e.g., The Netherlands).

The researchers set out to collect basic patterns of alcohol, tobacco, cannabis, and cocaine use in different countries. They documented lifetime use of these substances in each county, focusing on young adults. They also wanted to examine the age of onset of use and whether the type of drugs used was affected by one's social and economic status.

Other important results of this survey:

In the Americas, Europe, Japan, and New Zealand, alcohol had been used by the vast majority of survey participants, compared to smaller proportions in the Middle East, Africa, and China

The US has the highest levels of both legal and illegal drug use among all countries surveyed

Males were more likely than females to have used all drug types: legal and illegal

Younger adults were more likely than older adults to have used all drugs examined

Higher income was related to drug use of all kinds

Marital status was found to be linked only to illegal drug use

The use of cocaine and cannabis is more likely in people who have never been married or were previously married

PLoS Medicine is an excellent open journal , you can read the whole article or the editors'summary here

"Sequencing the cocoa genome is a significant scientific step that will allow more directed breeding of cocoa plants and perhaps even enhance the quality of cocoa, the key ingredient in chocolate," privately held Mars said in a statement.

In order to protect the cocoa bean and improve survival from diseases such as pest due to a higher disease resistance, MARS and IBM join together in exploring the cocoa genome.

"Sequencing the genomes of agriculture crops is a critical step if we want to better understand and improve a crop,"

About Me

Dr Shock is a pseudonym for a psychiatrist working in a University Hospital. His main topics of interest are the treatment of depression and electro convulsive therapy. Other subjects for this personal blog are research, article reviews, book reviews and education. He loves computers and Internet.